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NCLEX REVIEW 3 Questions With Complete Solutions
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NCLEX REVIEW 3 Questions With Complete Solutions
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NCLEX REVIEW 3 Questions With Complete Solutions0.33% NS Correct Answers is hypotonic solution
A 35-year-old patient presents to the emergency department
complaining of fever, chills, and headaches for the past two
days. There is a pink, macular rash on the palms, wrists, and
soles of the feet. Which statement by the patient would indicate
to the nurse a potential medical emergency? Correct Answers I
went hiking 2 weeks ago
Explain: The patient is experiencing symptoms of Rocky
Mountain Spotted Fever (RMSF): fever, chills, headache, and a
macular rash that appears on the palms of hands, wrists, soles of
feet, and ankles within ten days of exposure. RMSF occurs due
to Rickettsia rickettsii bacteria that can be transmitted to humans
via the Ixodes tick (deer tick). The patient has been hiking,
which puts them at risk for coming into contact with ticks.
RMSF is hard to diagnose in the early stages and without
treatment can be fatal.
A 4-year-old boy is recovering from abdominal surgery at the
pediatric unit. As the nurse caring for the child, which of the
following activities do you recommend that he prioritize?
Correct Answers Blowing bubbles
Explain: if the child is under the age of five or is unable to use
the incentive spirometer for another reason, they should blow
bubbles for two to three minutes every hour. Blowing bubbles
will serve as an alternative to incentive spirometry in these
children.
,A 55-year-old client with osteoarthritis develops coagulopathy
due to long-term NSAID use. The nurse caring for the client
understands that the client's coagulopathy is mainly the result of:
Correct Answers Decreased platelet adhesiveness
Explain: Platelets play vital roles in hemostasis and thrombosis
and can be inhibited by nonsteroidal anti‐inflammatory drugs
(NSAIDs). NSAIDs reduce platelet adhesiveness, therefore
impairing coagulation.
A client presents to the obstetrics floor at 39 weeks gestation
with irregular contractions. After you get the client situated in a
labor, delivery, and recovery room, you notice the client's health
care provider (HCP) enter the room to evaluate the client.
Following the evaluation, the HCP exits the room, and shortly
thereafter, you enter. During your discussion, the client states
the HCP "went to order oxytocin." In anticipation of that order,
you understand this client's oxytocin will be administered via
which route of administration? Correct Answers Intravenous
administration via piggyback using an infusion pump
Explain: Oxytocin should always be administered intravenously
as a piggyback infusion.
A male client with chronic renal failure has questions regarding
the effects of his kidney disease on his sexual activity. Which of
the following is a sexual complication of chronic renal failure?
Correct Answers Decreased testosterone
,Explain: Chronic renal failure causes decreased testosterone
levels. Low testosterone results in reduced sex drive
A mental health clinic is being constructed in a local
community. A nurse manager is hired to facilitate the unit's
nursing policies. Which of the following is the best resource for
these policies? Correct Answers Nurse Practice Act
Explain: The Nurse Practice Act describes the scope of nursing
practice. It directs the philosophy and standards of nursing. The
formulation of policies and procedures should be based on this
document.
A woman in her 30th week of gestation was brought into the
emergency department for falling down a flight of stairs. On
evaluation, the physician notes a rigid, board-like abdomen.
FHR is 167 bpm; with otherwise, stable vital signs. Which
obstetric emergency must be anticipated considering a possible
abdominal trauma? Correct Answers Abruptio placentae
Explain: External trauma can lead to abruptio placentae, the
complete or partial separation of the placenta from the uterine
wall. A sign that concealed hemorrhage has occurred is the rapid
increase in uterine size along with rigidity.
Acyclovir Correct Answers given to slow the growth of the
herpes virus
Although hepatitis B needs to be reported to the public health
department, a client with hepatitis B does not need to be
isolated. An appropriate client to room with would be an
, individual receiving intravenous diuretics for heart failure as this
client does not have any transmissible pathogens. Correct
Answers Measure the NG tube length from the bridge of the
nose to the earlobe to the halfway point between the umbilicus
and the xiphoid process.
Explain: For infants ( less than one year of age), the nurse
should measure the distance from the bridge of the nose to the
earlobe to a point halfway between the xiphoid process and the
umbilicus. This measurement ensures that the tube is long
enough to enter the stomach. However, for children older than
one year, the NG tube measurement should be from the bridge
of the nose to the earlobe to the xiphoid process.
Analyze the following ABG: pH 7.19, CO2 36, HCO3 12
Correct Answers Uncompensated metabolic acidosis
Explain: First, determine if the ABG is compensated or
uncompensated. Since the pH is not between 7.35 and 7.45, it is
uncompensated. Next, decide whether it is acidosis or alkalosis.
The pH is less than 7.35, so it is an acidosis. Lastly, determine if
it is respiratory or metabolic. Evaluate the CO2 and HCO3 to
see which is out of range. The CO2 is average, and the HCO3 is
low, so this is a metabolic problem. Putting it all together, you
have an uncompensated metabolic acidosis.
Analyze the following ABG: pH 7.36, CO2 69, HCO3 37
Correct Answers Compensated respiratory acidosis
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